Lebanon Veterans Home
600 North 5th Street, Lebanon, OR 97355 · Linn County · (541) 497-7265
154 certified beds, about 144 residents a day · Government - State · Medicare and Medicaid since 2014
CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
2 of 5
Staffing
5 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385280 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 9, 2025, inspectors cited 13 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 35 health citations since January 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.61 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.58 of those hours.
35.6% of nursing staff left within the year CMS measured (Oregon average 47.4%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
601/23
1605/24
1309/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 35 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
31D
3E
0F
Potential for minimal harm
0A
0B
1C
September 9, 2025Standard inspection · 13 citations
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure medications were not expired for 2 of 4 sampled houses reviewed for medication storage. This placed residents at risk for altered medication effectiveness.
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure proper food temperatures were maintained for meals served from 2 of 12 facility kitchens reviewed for food service. This placed residents at risk for unpalatable and unpleasant meals.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure infection control standards were followed in 1 of 4 houses reviewed for infection control. This placed residents at risk for spread of infection.
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain copies of advanced directives for 1 of 3 sampled residents (#13) reviewed for advanced directives. This placed residents at risk for not having their health care decisions honored.
- D Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure carpeting was clean for 1 of 3 houses (Delta 3). This placed residents at risk for an unhomelike environment.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect a resident's right to be free from physical abuse by a resident for 1 of 1 sampled resident (#68) reviewed for abuse. This placed residents at risk for injury.
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident was not started on a psychotropic medication without indication for use and failed to monitor a resident for side effects of psychotropic medications for 1 of 5 sampled residents (#123) reviewed for mood and unnecessary medications. This placed residents at risk for adverse medication reactions.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to update resident care plans for 2 of 3 sampled residents (#s 9 and 74) reviewed for ROM and infection control. This placed residents at risk for skin break down and inaccurate records.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents' neurological assessments were completed for 1 of 7 sampled residents (#135) reviewed for falls and rehabilitation. This placed residents at risk for unidentified head injuries.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received services to prevent accidents for 2 of 5 sampled residents (#s 9 and 74) reviewed for falls and rehabilitation. This placed residents at risk for injury.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a trauma assessment for residents with post-traumatic stress disorder (PTSD) for 2 of 7 sampled residents (#s 3 and 11) reviewed for psychotropic medications and unnecessary medications. This placed residents at risk for triggers related to PTSD.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor medications for 2 of 10 sampled residents (#s 3 and 4) reviewed for nutrition and unnecessary medications. This placed residents at risk for adverse medication side effects.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation and interview it was determined the facility failed to post complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information.
May 3, 2024Standard inspection, Complaint inspection · 16 citations
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide risk and benefits for the use of an antipsychotic medication to a resident/responsible party before administration and communicate changes in ROM services for 2 of 6 sampled residents (#s 80 and 118) reviewed for medications and positioning. This placed residents and responsible parties at risk for lack of appropriate information.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's physician of a change in condition for 1 of 3 sampled residents (#36) reviewed for UTIs. This placed residents at risk for delayed treatment.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for 1 of 1 sampled resident (#248) reviewed for notices. This placed residents at risk for lack of appeal information. Resident 248 was admitted to the facility in 2024 with diagnoses including heart attack and dehydration. A NOMNC documented the last covered day as 4/3/24. The NOMNC was signed by Resident 248 on 4/2/24. On 5/2/24 at 2:44 PM Staff 4 (Social Services Designee) confirmed the notice was not provided in the required timeframe to Resident 248.
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a sufficient grievance policy and a timely grievance response for 1 of 4 sampled resident (#128) reviewed for activities. This placed residents at risk for unaddressed concerns and grievances.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure residents were free from sexual and physical abuse for 2 of 5 sampled residents (#s 38 and 108) reviewed for abuse by Resident 139 and Resident 141. This placed residents at risk for abuse.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to timely investigate abuse for 1 of 3 sampled residents (#38) reviewed for abuse. This placed residents at risk for abuse and neglect.
- D Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review it was determined the facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for 1 of 5 sampled residents (#118) reviewed for nutrition. This placed residents at risk for unassessed needs.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to revise care plan interventions for 3 of 8 sampled residents (#s 38, 101 and 121) reviewed for accidents, pressure ulcers and position and mobility. This placed residents at risk for unmet needs.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 4 sampled residents (#80) reviewed for ADLs. This placed resident at risk for inadequate personal hygiene.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for 2 of 8 sampled residents (#s 36 and 118) reviewed for UTIs and medications. This placed residents at risk for delayed care and unmet needs.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to accurately assess pressure ulcers for 2 of 5 sampled residents (#s 59 and 118) reviewed for pressure ulcers. This placed residents at risk for worsening wounds.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess and care plan a resident's ability to transfer from a reclining chair and timely investigate a fall for 2 of 8 sampled residents (#s 121 and 142) reviewed for dementia care and accidents. This placed residents at risk for falls.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to obtain orders for oxygen for 1 of 1 sampled resident (#86) reviewed for respiratory care. This placed residents at risk for impaired respiratory status.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (#118) reviewed for medications. This placed residents at risk of jeopardized health status.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 1 of 5 sampled residents (#118) reviewed for medications. This placed residents at risk for unmet needs
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to practice proper infection control procedures for 1 of 5 sampled residents (#59) reviewed for pressure ulcers and sanitize resident care equipment for 1 of 3 halls. This placed residents at risk for infection.
January 30, 2023Standard inspection · 6 citations
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess a resident's ability to safely self-administer medications for 1 of 6 sampled residents (#122) reviewed during medication pass. This placed residents at risk for unsafe medication administration.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's physician was notified of a change in AIMS (abnormal involuntary movement scale) score for 1 of 5 sampled residents (#128) reviewed for medications. This placed residents at risk for lack of physician notification.
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident grievances were addressed in a timely manner for 1 of 2 sampled residents (#116) reviewed for personal property. This placed residents at risk for unaddressed grievances.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident centered care plan was developed for 1 of 3 sampled residents (#116) reviewed for activities. This placed residents at risk for lack of care planning.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop an activity program to meet resident's needs for 2 of 3 sampled residents (#s 91 and 116) reviewed for activities. This placed residents at risk for lack of meaningful activities.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 106 and 117) reviewed for medication and range of motion. This placed residents at risk for reduced efficacy of medications and decreased range of motion.
Fire safety inspections
15 fire safety citations on file: 2 on September 9, 2025, 3 on May 3, 2024, 10 on January 30, 2023.
Every fire safety citation15 citations
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E Ensure proper usage of power strips and extension cords.
- F Develop and maintain an Emergency Preparedness Program (EP).
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Establish procedures for tracking staff and patients during an emergency.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Install smoke barrier doors that can resist smoke for at least 20 minutes.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Have restrictions on the use of portable space heaters.
- E Meet requirements for the installation and maintenance of electrical systems.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.61 | 5.03 | 3.86 |
| Registered nurses | 0.58 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.83 | 4.51 | 3.42 |
| Nurse aides | 3.57 | ||
| Licensed practical nurses | 1.45 | ||
| Nursing staff turnover (share who left in a year) | 35.6% | 47.4% | 45.8% |
| Registered nurse turnover | 40.9% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.50 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.93 on weekdays and 4.83 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.49 in April to June 2025 to 5.61 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.61 | 0.58 | 5.93 | 4.83 | 4.8% | 0 of 90 | 144 |
| Oct to Dec 2025 | 5.51 | 0.55 | 5.82 | 4.71 | 4.5% | 0 of 92 | 143 |
| Jul to Sep 2025 | 5.54 | 0.61 | 5.92 | 4.56 | 4.3% | 0 of 92 | 143 |
| Apr to Jun 2025 | 6.49 | 0.57 | 6.92 | 5.43 | 6.1% | 0 of 91 | 145 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 28.1 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.7 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.1 | 2.4 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 19.2 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.4 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 16.6 | 13.9 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.9 | 2.4 | 1.8 |
Owners and operators
Legal business name: STATE OF OREGON DEPARTMENT OF VETERANS AFFAIRS.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| State of Oregon Department of Veterans Affairs | 5% or greater direct ownership interest | Organization | 100% | 10/01/2014 |
| Andrade, Abraham | W-2 managing employee | Individual | 06/14/2022 | |
| Haole Valenzuela, Donna | W-2 managing employee | Individual | 03/01/2022 | |
| Veterans Care Centers of Oregon | Operational/managerial control | Organization | 10/01/2014 | |
| Westcare Management Inc | Operational/managerial control | Organization | 10/01/2014 | |
| Decker, Bryan | Operational/managerial control | Individual | 06/14/2022 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 10 problems in this area, most recently on September 9, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 9 problems in this area, most recently on September 9, 2025: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive."
- When is the care plan meeting, and can family attend it?Inspectors cited 5 problems in this area, most recently on September 9, 2025: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 4 problems in this area, most recently on September 9, 2025: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
Other nursing homes nearby
- Avamere Rehabilitation of Lebanon Lebanon, 0.8 mi · 1 of 5 stars · 60 citations
- Mennonite Home Albany, 8.8 mi · 4 of 5 stars · 20 citations
- Regency Albany Albany, 11 mi · 2 of 5 stars · 33 citations
- Timberline Post Acute Albany, 11.7 mi · 5 of 5 stars · 20 citations
- Corvallis Manor Nursing & Rehabilitation Center Corvallis, 17 mi · not rated · 82 citations
- Salem Transitional Care Salem, 23.2 mi · 2 of 5 stars · 35 citations
- Avamere Transitional Care at Sunnyside Salem, 24.2 mi · 2 of 5 stars · 52 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Lebanon Veterans Home's Medicare star rating?
- CMS rates Lebanon Veterans Home 3 out of 5 stars overall, with 2 for health inspections, 5 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Lebanon Veterans Home get at its last inspection?
- 13 health deficiencies at the standard inspection on September 9, 2025. The Oregon average is 9.2.
- Has Lebanon Veterans Home been fined?
- CMS lists no fines in the last three years.
- Does Lebanon Veterans Home accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Lebanon Veterans Home?
- CMS lists 6 owners and managers. Legal business name: STATE OF OREGON DEPARTMENT OF VETERANS AFFAIRS.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.